Employee Occupational Health Assessment- Initial Preplacement

The purpose of this evaluation is to screen for communicable diseases and to determine if there are any physical, mental, or emotional impairments that could affect your ability to perform the job that you have been offered. Whenever such impairment is identified, we will attempt to specify restrictions which may

allow you to perform the job safely while still successfully performing the essential functions of the job. This evaluation is not a comprehensive health review to identify hidden disease or to offer medical treatment.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic information of an individual or

family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic Information” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received

genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Name (Print) first name, middle initial, last name / Duke unique ID #
Address: / Cell/Home phone:
City, State, zip code: / Birth date:
Previous Job title/ work location:
Title of the job you have been offered: / Do you require credentialing Y N
Dept/work area: / Work phone:
Supervisor/ Manager: / Hosp Campus:
Duke DRH Duke Raleigh

Employment Information

Will you work with: Blood Body Fluid Exposure Patient Contact Lab animals
Do you have any current disability or physical condition requiring restricted activity? Yes No
Do you have any lifting restrictions. Yes No
If yes, state restrictions: Use separate sheet if needed
If yes, are these restrictions:
Permanent Temporary until
Do you have decreased ability to lift, carry, push/ pull, and
transferpatients and/or equipment/ materials as describedin
youremployment interview and/or health assessment.
Y N / Have the physical demands of the job been described to you?
Yes No Uncertain
Please state your understanding of the amount
of weight and frequency of lifting required in this job:
______lbs. (ex. Up to 10, 25, 30, 50, 75, or over 75 lbs.)
______frequency (ex. Up to 1/3, 2/3,or whole shift)
Can you perform the essential functions of this job?
Yes No Uncertain
If no, will you require a job modification to accommodate
a disability?
Yes No Uncertain
If yes, please explain:

Occupational History – List your last three positions, starting with the most recent.

TITLE / BRIEF JOB DESCRIPTION / DUTIES PERFORMED
1
2
3

I certify that the following information is true to the best of my knowledge. I understand and agree to authorize Duke Employee Occupational Health & Wellness to review any information (including, but not limited to, information relating to psychiatric/psychological and alcohol and substance abuse diagnosis and treatment, if any such information exists) at Duke or other health care providers for purposes related to my fitness for employment. I agree to any reasonable subsequent testing or evaluation deemed necessary to determine my fitness to perform this job, and I authorize the examining provider to forward pertinent information to those who would perform such testing or evaluation.I understand that Duke is relying upon my representations contained herein and they are substantial employment factors. I further understand that misrepresenting the facts may result in forfeiture of this employment opportunity. I understand that this information will become part of my confidential Employee Occupational Health record and is not shared with management.

Signature of applicant / Date

Functional Self-Assessment Duke ID ______

(Check all that apply)
  1. Have you developed any of the following?
Y N Loss of vision in either eye that cannot be
corrected
Y N Loss of vision requiring correction
select type of correction needed (if applicable):
Near Correction Far Correction
Eyeglasses Lasik Contact Lenses
Y N Do you have any color vision deficiencies?
Y N Loss of hearing that is corrected.
Y N Loss of hearing that is not corrected.
  1. 2. Do you have decreased function in any of
the following?
Y N Either arm/hand, including grip/reach, use of
fingers
Y N Neck, or lower back (such as arthritis, or
pinched nerve)
Y N Hips, knees, ankles, or feet
  1. Do you have decreased ability in any of the following?
Y N To stay awake or maintain consciousness
(due to such causes as seizures, diabetes, or sleep
disorder)
Y N To breathe or maintain endurance (due to
such causes as asthma, emphysema, or angina)
Y N To fight off infection (due to such causes as
immune deficiency, diabetes, HIV infection, drugs for
Rheumatoid arthritis, cancer, and other illnesses).
If yes to any of the prior, provide comments: / Continue if needed:
  1. Do you have physical problems (such as
seizure disorder, diabetes, allergies) or
mental/emotional problems (such as anxiety,
attention deficit disorder, or claustrophobia)
that could interfere with any of the following?
Y N Working with soaps, detergents
Y N Wearing gloves
Y N Using a respirator
Y N Using latex products
Y N Working rotating shifts (nights, evenings)
Y N Working with animals
Y N Working with radiation or chemotherapy agents
Y N Managing multiple tasks at one time
Y N Focusing on job tasks
If yes to any of the above, provide comments:
Y N 5. Have you been vaccinated against polio?
Y N 6. Have you had the Hepatitis B vaccine series?
Month/Year Completed Series ______
Y N 7. Do you have questions regarding general health,
Reproductive health, or other safety issues at work?
7. List ALL current medications/treatments (including non prescription), the condition treated, date begun.
Medication Dosage Condition Date
______
______
______
______
______
8. Yes No Do you now or have you ever had a substance abuse/dependence problem?
9. Yes No Do you now or have you ever had an alcohol abuse/dependency problem?
Reviewer’s Signature / Date of signature - mm/dd/yy

Common/EOHW FORMS/PlacementHealthRevForms/InitialPlacementHealthReview 03/19/2013